ステントグラフト内挿術が有用であった感染性大動脈瘤の1治療例

A Case of Endovascular Treatment with Stent-graft for a Mycotic Aneurysm of the Thoracic Aorta

要旨　患者は61歳，男性．発熱を伴う前胸部痛にて入院．前胸部の皮下膿瘍を認め，膿瘍培養と血液培養からペニシリン感受性肺炎球菌を検出した．抗生剤投与にて皮下膿瘍は軽快するも，胸部下行大動脈に囊状動脈瘤が出現した．一方，僧帽弁後尖への疣腫がみられ，感染性心内膜炎の併発と診断された．その後，動脈瘤が急速に増大，進行したため，破裂の危険が高い感染性胸部大動脈瘤であると診断し，緊急避難的処置としてステントグラフト内挿術を選択，施行した．一般的に，感染性大動脈瘤に対するステントグラフト内挿術は相対的禁忌とされる．しかし，結果的に企画していた外科的血行再建術も不要となり，合併症併発もなく，好ましい臨床経過で推移した．本症におけるステントグラフト内挿術の適応拡大の可能性を示唆した貴重な1例であると考え報告する．

A 61-year-old man was admitted to our hospital due to sustained fever and anterior chest pain together with a subcutaneous abscess on the fore-chest. Both of the cultures from the abscess and blood demonstrated positive for Streptococcus pneumoniae. Systemic administration of sensitive antibiotics remitted the abscess and inflammatory response, while a rapid enlarging and expansion of a descending aortic aneurysm was recognized together with vegetation on the mitral leaflet. As an emergent procedure, temporary treatment for the mycotic aortic aneurysm, which was about to rupture, endovascular treatment with a stent-graft was chosen. The patient's clinical course thereafter improved dramatically without additional surgical repair or any postoperative complications. Although endovascular treatment with a stent-graft for a mycotic aortic aneurysm has been contra-indicated so far, individual exceptions should be discussed for not only temporary but also permanent results.